Early Findings

In the early years of developing and applying the Sanctuary Model to the original population – adults who had been abused as children – in acute care, inpatient settings, research wasn’t even on the “radar” screen. It was all we could do at the time just to keep the program alive in an era of ever-decreasing resources and none of us were research-inclined or trained. We specialized in treating trauma survivors from 1991-2001 and during that time treated thousands of men and women, all of whom were admitted because their symptoms had become in some way life-threatening and therefore necessitating inpatient hospitalization. We did not use seclusion or restraint and had an open-door program. We still occasionally hear from people who were treated on our unit and the other day received an email from a woman who had a stay in our program in 1992.

From Chaos to Sanctuary

The first application of the Sanctuary Model in another setting was initiated by Dr. Lyndra Bills in a state hospital setting [1-2]. When Dr. Bills first arrived to become the Medical Director of a unit filled with chronically hospitalized women, the violence on the unit was pervasive. As she described her arrival at the unit on her first day,

The sound of women’s screams filled the air and as I stared, halted in my progress for a moment, a chair flew across the hallway and crashed to the floor, and then a large woman, presumably a patient, came up behind a staff member and began to pound the nurse on the head. The level of reported violence, particularly self-harming behavior, that was an endemic part of this environment, convinced me that there must be a high level of previously unrecognized and unresolved traumatic experience in the backgrounds of these patients, a finding that has been recognized in previous research.

As Dr. Bills quickly discovered, the situation was far from ideal. There were only two psychiatrists in the whole facility and they were responsible for 250 patients, and for the women on her unit there was literally no therapeutic program. The nursing staff had been instructed to carefully chart the patients’ behavior, but not to engage them. There were twenty-four women on the unit, all involuntarily committed. Of these twenty-four, 25% had been hospitalized for six months to four years, while another 25% and been in this hospital for more than a decade. Their average age was only 38 and 50% of them had a high school degree or equivalency and two even had Master’s degrees. But most of them were diagnosed with schizophrenia.

The nursing staff were intimidated by the amount of violence – over 100 reported violent incidents a month and that did not include the hundreds of other incidents that were not reported. Staff were reluctant to establish rules that could decrease violence because they feared there would be untoward consequences. There were two nurses and four-six aides on every shift but four of these staff were doing one-to-one nursing on four of patients and another two staff doing two-to-one nursing on one other patient – twenty-four hours a day, seven days a week. The nurses were clear that the job they had been instructed to do was to observe, record, and report. There was rarely any talking between staff and patients, no social workers, no psychologists, or other unit-based support. Although the hospital had some strong therapeutic programming including art therapy, recreational therapy, work programs, and psychoeducational programming, these patients were not considered to be safe enough to participate in these activities. What structure that existed on the unit was imposed by the most basic needs or desires of the patients - the desire to eat, to smoke or to have a pass. Patients were neither expected nor required to attend programming or to engage in treatment in any way. The barriers to any kind of therapeutic progress were immense.

The amount of violence was astonishing. Employee time was lost as a result of being bitten, hit, splashed with hot coffee, and kicked. The average lost time was about 20 hours per month at the peak of the violence, but in one month alone there was 74.5 hours of employee time lost from work. Everyone abhorred the violence but felt helpless to do anything to stop it, nor were any real efforts made to understand the factors that may have provoked it. The patients were frequently and unremittingly violent towards staff members who resorted to the use of seclusion and restraint as their only defense against serious harm. The level of self-mutilation was astonishing and terrifying. One of the environmental reasons for this behavior rapidly became obvious. Being taken to the emergency room for suturing of self-inflicted wounds was one of the only times that a patient could count on the undivided attention of another human being and receive caring physical touch.

Even in those early days it was apparent to me that the patients were engaged in some kind of bizarre reenactment behavior that was satisfied only by the use of strait jackets and solitary confinement. One woman, sexually and physically abused first by her family and then later in foster care, would repeatedly smash pieces of glass to put into her eyes. Another would repetitively and compulsively insert dangerous objects into her vaginal canal and demand that the physician remove them. Not surprisingly she was a known victim of incest. A woman who had been horrifically physically abused by her father, would engage in situations with staff that would escalate to violence necessitating an emergency call to male staff members in the hospital who would rush to assist the staff, wrestle the patient into submission and tie her in restraints. In this scenario she managed to use the staff to recreate a scenario of her own childhood over and over again...No one was immune I was hit in the head, thrown down steps, and repeatedly threatened. The patient who was on constant two-to-one supervision was a young woman diagnosed with dissociative identity disorder who was so volatile that she only was allowed to get air outside while cloaked in a strait jacket behind an enclosed and walled courtyard [2].

Dr. Bills began “reclaiming” the environment by first learning about the patients’ voluminous histories and then training the staff in trauma theory. She used the first paper published to explain the Sanctuary Model as a guideline for what she needed to do [3]. She rediagnosed sixty percent of those carrying a schizophrenic diagnosis and of these, fifty percent met criteria for post-traumatic stress disorder or a dissociative disorder. She began aggressively treating people and introduced therapeutic methods and procedures into the program.

Gradually, instead of being some autonomous and unknowable force in the environment, the violence became meaningful and relational in context -It began to make sense and as a result the violence began to diminish. A striking salute to the effectiveness of the trauma-based approach was that during the month of October, 1994 no seclusion or restraint was used. This was a first in the history of the institution. Five years after Dr. Bills left, one of the original patients had died, but only one remained in the hospital. All the rest have been discharged and in that five year period had not been readmitted. The dissociative identity disorder patient who had consumed so many months of two-to-one supervision was released from the hospital thirty months after her admission and at least two years after discharge had not self-harmed, been suicidal, or been rehospitalized.

Until I introduced trauma theory, no one had understood the trauma-based nature of the patients’ symptoms and had consistently labeled that behavior “crazy” or “bad” – and therefore not really subject to change. The trauma model allowed the staff to see the patients as having the potential to change, not needing to be hospitalized for the rest of their lives. They came to believe that if we were able to address the reasons they were there, they could heal enough to live more functional lives outside of the hospital. This sense of hope was contagious, spreading from me to the staff and on to the entire patient community.

A Canadian Experience

The second set of early findings came from a program at Homewood Hospital in Guelph, Ontario, a program that still exists today. After consulting with the Sanctuary Model founders and receiving some trauma-informed training, the managers of the unit developed a six-week inpatient stay and began evaluating their work which they subsequently published. In the study, 132 people with a mean age of 40 and comprising only 14% men were evaluated. All of them were admitted with a past history of some kind of maltreatment prior to the age of seventeen and 58% had a history of two or more types of abuse. Instruments evaluating improvements were administered at admission, discharge and for a third of the clients again at three months and one year post-discharge. The results demonstrated that the clients had experienced significant positive changes over time [4-5].

Bennington-Davis and Murphy began an intensive exploratory experience with their colleagues on the unit and actively trained themselves and everyone else in the principles of the Sanctuary Model, combining these ideas with important knowledge about substance abuse treatment, management of early psychosis, and consumer relations. In doing so, the program began to emphasize respect and dignity, support for autonomy, a focus on recovery and patient satisfaction, an awareness of the trauma to clients and staff associated with seclusion/restraint, a shifting of power and control from management downward and into the client community, and an increase in patient and family involvement. Community Meetings were instituted and led by the clients with active participation of the staff, the general environment of the unit was renovated and made more human-friendly, Psychoeducation became a routine aspect of the daily interactions on the unit, intensive debriefing occurred after any incidents of even minor violence.

In less than a year reduced the rate of seclusion and restraint by over 85% and subsequently had extended period of time without any seclusion or restraint at all. They noted a 1/3 reduced “forced” emergency medications, increased voluntary patient participation in medication use, an overall decrease in doses of medication, decreased use of intramuscular antipsychotic medications, increased patient engagement with therapeutic groups, reduction in all forms of violence, reduced use of employee health service for injuries related to violence, reduced time off for work injuries related to violence, significantly decreased staff turnover and increased staff morale. The program was awarded the Oregon State Mental Health Award of Excellence in 2002 [6].

NIMH Research Project

In previous research, implementation of the Sanctuary Model has met with many challenges, primarily in changing the way staff conduct business as usual and in changing the organizational culture. In studying children’s service systems, investigators found that organizational climates with greater job satisfaction, fairness, cooperation, and personalization, and lower levels of conflict were associated with both service quality and positive outcomes in children’s psychosocial functioning. We believe that these findings are relevant, not just to children’s services but to services directed at all ages of people with complex behavioral and social problems.

In 1999, the Jewish Board of Family and Children’s Services (JBFCS) in New York asked Dr. Bloom to assume the Sol Z. Cohen Chair in order to investigate the application of the Sanctuary Model to the residential treatment of children. Dr. Bloom collaborated with Dr. Jeanne Rivard and a team of clinicians from JBFCS to formulate a research project to examine the implementation and proximal effects of the Sanctuary Model as an intervention designed to reduce trauma-related symptoms of youth that place them at risk for violent behavior, poor adjustment, and serious mental health difficulties. Dr. Rivard, then at Columbia University’s School of Social Work, perceived that The Sanctuary Model as it was developed at the time was comprised of two primary components: the creation and maintenance of a non-violent, democratic, therapeutic community and a psychoeducational program. A study was then designed around these components and funded by the National Institute of Mental Health R21 funded research collaboration and conducted at the Westchester campus of the Jewish Board of Family and Children Services. The study was extensive and the research reports are available in the literature so we won’t detail the nature of the study here, but just review some of the key findings.

In the Sanctuary Model cottages, compared to a control group, there were significant positive changes in the staff perception of themselves and the clients on the following measures: Support: how much clients help and support each other; how supportive staff is toward clients; Spontaneity: how much the program encourages the open expression of feelings by clients and staff; Autonomy: How self-sufficient and independent clients are in making their own decisions; Personal Problem Orientation: the extent to which clients seek to understand their feelings and personal problems; Safety: The extent to which staff feel they can challenge their peers and supervisors, they can express opinions in staff meetings, they will not be blamed for problems, and there are clear guidelines for dealing with clients who are aggressive.

Staff became aware that the extent and nature of their own communication was integral to the creation of a safe treatment setting. Similarly, a more psychologically and socially safe environment encouraged staff to openly share their ideas, opinions, frustrations, and mistakes. There was a general observation that the quality of team meetings and case conferences had improved with more active involvement and communication of all staff, and that these meetings provided a forum for practicing how to deal with program issues in non-hierarchical and more complex ways. Factors that promoted implementation included: staff training; use of a shared language and conceptual framework; Community Meetings; building in sufficient time for discussing implementation and team building; keeping everyone motivated, capturing successes, promoting group cohesion, a psychoeducational framework for staff and clients, and strong leadership involvement. Factors which posed barriers to model implementation and consistency included: insufficient time to do the constant communication and teambuilding needed; conflicts in the ways in which different components of the program handled crises; lack of consistent and universal training; insufficient leadership involvement.

McSparren Evaluation

Wendy McSparren (2007) took the evaluation of Sanctuary implementation a step further by examining not just differences in units within the same agency; but, between separate agencies. Study participants were recruited from five mental health/ social service agencies – three using the Sanctuary model and two that were not. She asked participants to complete a questionnaire measuring attitudes toward change and the Denison Organizational Culture Survey measuring agency culture in terms of adaptability, involvement, consistency & mission [7-8]. McSparren found that, although there were no significant differences in attitudes toward change between staff at the different agencies, staff members in the Sanctuary agencies reported statistically more positive differences in their organizational culture than the staff members of non-Sanctuary agencies. In short, she found support for the use of the Sanctuary Model in positively impacting the culture of the workplace[9].

Wright, D.C. and W.L. Woo, Treating Post-Traumatic Stress Disorder in a Therapeutic Community: The Experience of a Canadian Psychiatric Hospital. Therapeutic Communities: The International Journal for Therapeutic and Supportive Organizations, 2000. 21(2): p. 105-118.